Monday April 23, 2007 Volume 1, Issue 1

Monday April 23, 2007 Volume 1, Issue 1

Advances in Low Back Pain Research by Physical Therapists, for Physical Therapists

Subgrouping improves Outcomes A recent study by Brennan et al (2006) concluded that subgrouping improves outcomes in patients with acute and subacute Low Back Pain. Groups included manipulation, specific exercise, and stabilization. Inclusion in a subgroup followed the criteria determined by previous research from Flynn1, Childs2, and Hicks3, defined below. Brennan GP, Fritz JM, Hunter SJ, Thackeray A, Delitto A, Erhard RE. Identifying Subgroups of Patients with Acute/Subacute “Nonspecific” Low Back Pain. 2006. Spine 31(6) 623-631. Subjects  Inclusion: 18-65 years, LBP of <90 days duration, with or without referral to the LE, Oswestry Disability Questionnaire (ODQ) >24%.  Exclusion criteria: visible lateral shift or acute kyphotic deformity, signs of nerve root compression (+ SLR and reflex or strength deficits), presence of red flags, inability to reproduce symptoms, pregnancy, prior surgery to lumbar or sacral spine. Results  At 4 weeks, the difference favoring the matched treatment group (patients treated according to subgroup) was 6.6 points on the ODQ (95% CI 0.7-12.5)  At 1 year, the difference in ODQ was 8.3 points (95% CI 2.5-14.1) favoring the matched treatment group.

Treatment

Criteria for Subgrouping MANIPULATION Patients meeting 4 of 5 criteria were found to have a 92% chance of achieving 50% improvement in ODQ after 4 weeks2. Criteria1,2  Symptoms < 16 days  No Pain Below the Knee  Lumbar hypomobility with PA assessment  FABQ work subset <19  Hip IR a minimum of 35 degrees in 1 hip STABILIZATION Patients meeting 3 of 4 criteria increased the odds of achieving a 50% improvement in ODQ from 33% to 67%3. Criteria  Age <40 years  Average SLR >91  Aberrant movement  (+) Prone instability Test

   

 



SPECIFIC EXERCISE  

Centralize with 2 or more movements in the same direction -ORCentralize with a movement in one direction and peripheralize with an opposite movement

characterized by the presence of leg symptoms



either peripheralization with extension movements or a crossed

signs of nerve root compression (altered reflex, dermatomal or myatomal changes)

STABILIZATION 2 visits/week for 8 weeks Repeated submaximal efforts mimicking the function of muscles during spinal stabilization. Challenges to the erector spinae, multifidus and quadratus lumborum in supine, quadruped, sidelying and standing

SPECIFIC EXERCISE  

Repeated ROM exercises Based on preference indicated during evaluation

  

12 minutes (1 minute ramp up/down) 40%-60% of body weight Moving toward neutral or extension

TRACTION

 

MANIPULATION Spinal manipulation and supine pelvic tilt AROM for the first 2 visits Advice to maintain usual activity Aerobic exercise Lumbar spine strengthening program

TRACTION

REFERENCES 1. Flynn T, Fritz J, Whitman J, et al. A Clinical Prediction Rule for Classifying Patients with Low Back Pain who Demonstrate Short-Term Improvement With Spinal Manipulation. Spine 2002;27:2835-43. 2. Childs J, Fritz J, Flynn T, et al. A Clinical Prediction Rule to Identify Patients with Low Back Pain Most Likely to Benefit from Spinal Manipulation: A Validation Study. Ann Intern Med 2004; 141:920-928. 3. Hicks G, Fritz J, Delitto A, McGill S. Preliminary Development of a Clinical Prediction Rule for Determining which Patients with Low Back Pain will Respond to a Stabilization Exercise Program. Arch Phys Med Rehabil 2005; 86:1753-62. 4. Fritz J, et al. Is there a subgroup of patients with low back pain likely to benefit from mechanical traction? SPINE 2007; 32(26): E793-800.